Medical Advisory Board

* First Name:
* Last Name:
* City:
* State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
* Phone Number:	() -
* E-mail Address:
* Degree::	MD DO PharmD Rph NP RN Other
* Area of Expertise:	Anesthesiology Cardiology Critical Care Dermatology Endocrinology Emergency Medicine Gastroenterology Geriatrics Hepatology Hospital Medicine Infectious Diseases Internal Medicine Neonatology Nephrology Neurology Oncology Ophthalmology Pain Pediatrics Pharmacy Physiatry Podiatry Psychiatry Pulmonology Radiology Surgery, General Surgery, Vascular
* How do you prefer to be contacted?:	E-mail Phone
Which of the following is your preferred format for obtaining CE/CME:	Local dinner meeting Weekend half-day meeting National conferences Internet Print monographs CD-ROM Audio conference Podcast Other
	(Please check all that apply)
Which of the following teaching methods do you prefer:	Didactic lecture Open Q & A Case Studies Panel Discussions Other
	(Please check all that apply)
I would be interested in attending the following activities:	ALL TOPICS LISTED Cardiology Dermatology Diabetes Infectious Disease Asthma/COPD Psychiatry Pain Management Anticoagulation/Thrombosis Immunizations HIV/AIDS Epilepsy/Seizures Other
	(Please check all that apply)

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